Provider Demographics
NPI:1871757070
Name:ROBERTS, JONATHAN CHARLES (MD)
Entity type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:CHARLES
Last Name:ROBERTS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:427 W NORTHMOOR RD
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61614-3542
Mailing Address - Country:US
Mailing Address - Phone:309-692-5337
Mailing Address - Fax:309-693-3913
Practice Address - Street 1:427 W NORTHMOOR RD
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61614-3542
Practice Address - Country:US
Practice Address - Phone:309-692-5337
Practice Address - Fax:309-693-3913
Is Sole Proprietor?:No
Enumeration Date:2008-07-16
Last Update Date:2021-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI55876208000000X, 2080P0204X
IL125.054688208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2080P0204XAllopathic & Osteopathic PhysiciansPediatricsPediatric Emergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1871757070Medicaid